Sociocognitive factors determining compliance with standard precautions by nursing professionals during the COVID-19 pandemic

ABSTRACT Objectives: to assess the socio-cognitive factors determining adherence to standard precautions by nursing professionals in care practice during the COVID-19 pandemic in Brazil. Methods: an analytical cross-sectional study, carried out with 9,039 nursing professionals in Brazil, using an electronic form containing participant sociodemographic, training and work variables, and the Brazilian version of the Standard Precautions Questionnaire. Descriptive and inferential statistics were used using the statistical software R. Results: participants recognize standard precautions as effective measures to reduce infections and report intention to perform them. Training regarding standard precautions was evidenced as a facilitator of adherence (4.72; SD: 0.73), and problems related to materials (3.78; SD: 1.45) were a hindrance. Conclusions: among the determining factors, facilitating organization presented the highest score, followed by intention to perform. Facilitating and hindering factor identification makes it possible to develop intervention strategies to strengthen patient safety and reduce occupational risks among professionals.


INTRODUCTION
Standard precautions (SP) consist of preventive measures against infection, which must be followed by healthcare professionals, in any environment, considering that all patients are potentially infected by a pathogen that can be widely disseminated.They include using personal protective equipment (PPE) (cap, protective glasses or face shield, mask, gloves and protective apron), due to the risk of exposure to blood, body fluids, excretions and secretions, in addition to hand hygiene, correct handling and disposal of sharps (1) .
In light of the coronavirus disease 2019 (COVID-19) pandemic, among the prevention measures, the relevance of following SP was highlighted, especially in the absence of a confirmed diagnosis of patients, aiming to reduce COVID-19 infection in this scenario, in addition to other occupational risks and minimize cross-transmission of infectious diseases (2) .
Studies that investigated adherence to SP showed an insufficient rate among healthcare professionals, with the majority being below what was desired, with rates varying from medium to low, in addition to a high rate of inappropriate use of PPE (3)(4)(5)(6)(7) .
It is worth highlighting that socio-cognitive determinants encompass social and cognitive factors, which influence human behavior and decision-making, in this case, of nursing professionals.Therefore, socio-cognitive determinants are fundamental to understanding human behavior and, thus, implementing strategies that enable changes.For instance, studies (8) indicate that socio-cognitive factors, such as knowledge, motivation, intention, expectations and perceptions, influence behavior related to hand hygiene.Adherence to SP can be positively influenced by attitudes and behaviors related to the control and prevention of infections, through knowledge and social factors.Therefore, individual and organizational factors can play a relevant role in behavioral intentions regarding this practice (9)(10)(11) .
Thus, adherence to SP can be hampered by numerous factors: individual factors, such as awareness, risk perception, perception of the effectiveness of protective measures, beliefs and values, knowledge, subjectivity, interpersonal relationships; work-related factors such as workload, work obstacles; and organizational factors, such as availability and quality of PPE, physical structure, supervision, management actions (3,5,(12)(13) .
Among the main reasons, the quantitative and qualitative inadequacy of PPE stands out, while the lack of awareness and deficiencies in training, including personal beliefs, can also be obstacles, as they directly impact personal perception of risk and, consequently, the extent of protection adopted and risk behavior assumed.Furthermore, the lack of continuing education, inadequate related working conditions, mainly excessive working hours, reduced teams and intense work pace are factors that require improvement with the aim of a more favorable environment for adhering to SP.It is worth remembering that, as a consequence of low adherence to SP, work accidents are recorded due to exposure to potentially contaminated biological material and workers becoming ill (14) .
In relation to healthcare professionals, it is necessary to highlight nursing professionals, who were on the front line in the fight against COVID-19, given their high representation in the health sector, approximately 59% of the global health workforce (15) .Therefore, they were directly impacted by the pandemic and the factors that make it difficult to adhere to SP, recording a high number of confirmed cases and deaths.
Therefore, few studies focus on socio-cognitive determinants, the factors involved and nursing professionals' behavior.Therefore, it is important to better recognize and assess these determinants through the application of the scale proposed in the present study, aiming to identify the facilitating and hindering factors involved with non-adherence to SP as a preventive measure in patient care, thus enabling the determination of new strategies that promote the reorganization of the work environment and encourage a safety culture, aiming at professional and patient safety.

OBJECTIVES
To assess the socio-cognitive factors determining SP adherence by nursing professionals in care practice during the COVID-19 pandemic in Brazil.

Ethical aspects
The project was approved by the Research Ethics Committee (REC) of the Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo.
The scale was used with the authorization of its author, who is also part of this investigation.Data were collected after approval by the REC and upon acceptance of the Informed Consent Form (ICF), available online next to the form, by selecting the option "I have read and agree to participate in the research".

Study design and location
This is a cross-sectional and analytical study, carried out through an online survey with nursing professionals from all regions of Brazil.The research followed the recommendations of STrengthening the Reporting of OBservational studies in Epidemiology for RDS studies (STROBE-RDS) and was guided by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

Sample and inclusion criteria
Nursing professionals aged 18 or older, with internet access and who worked in direct assistance to patients, whether or not affected by COVID-19, in the different health care settings, in Brazilian territory, during the COVID-19 pandemic, at least in the last six months prior to the beginning of collection, were included.Professionals who did not respond to the research instrument completely were excluded.

Data collection
Research participants were recruited using an adaptation of the Respondent Driven Sampling (RDS) method to the virtual environment.Thus, 47 research leaders were selected by the research team, at least one from each state in Brazil, responsible for nominating ten recruiters.Each recruiter nominated ten research participants and they nominated other potential participants, and so on.Leaders  recruiters underwent online training on how to conduct an online survey in the context of the pandemic and on the questionnaire to be administered.A total of 280 collectors were trained in 45 sessions.
A pilot study was carried out with 47 respondents, who sent feedback or comments about the survey.The suggested changes were considered and small adaptations of terminology.
Data collection took place from October 1 to December 31, 2020, using an electronic form, created by the research team and assessed in terms of face and content by 15 experts on the subject.It was made available through a link to SurveyMonkey ® , the software in which the completed instruments were hosted.

Data collection instruments and study variables
The electronic form consisted of two parts.The first contained objective questions with independent variables regarding sociodemographic, training and work characteristics.
The second part of the form was composed of the Brazilian version of the Standard Precautions Questionnaire (SPQ-PB) (16) , which assesses the socio-cognitive factors determining SP adherence in hospital settings, covering attitudes, behaviors, individual and organizational limitations and constraints.It has 24 items distributed across seven determining socio-cognitive factors: 1 -Attitude toward standard precautions (items 1 to 3); 2 -Social influence (items 4 to 7); 3 -Facilitating organization (items 8 to 10); 4 -Exemplary behavior (items 11 and 12); 5 -Organizational constraints (items 13 to 16); 6 -Individual constraints (items 17 to 20); 7 -Intention to perform standard precautions (items 21 to 24).The answer options consist of a scale ranging from 1 to 5.

Data treatment and analysis
The collected data were exported and analyzed by the statistical software R, version 4.1.1,using descriptive statistics, with absolute and relative frequency measures for all categorical variables, and central tendency (mean) and dispersion (standard deviation) for all continuous variables.
The overall score, by item and by socio-cognitive factors determining the scale were calculated through the average of the answers obtained on a Likert scale from 1 to 5. The determining socio-cognitive factors assessed consist of the seven factors of the scale.To compare the means between the groups, the scores of SPQ-PB domains and professional categories were used, applying the Mann-Whitney test.The analyzes considered a significance level of 5% (α=0.05).

RESULTS
Nursing professionals 9,039 (100%) participated in the study (Table 1), the majority of whom were female (7,634; 84.5%) and aged between 18 and 30 years (3,350; 80%).The median age was 34 years (IQR= 12).Time since graduation was ten years, and the experience in the role was nine years.The majority are from the Northeast region (2,728; 30.2%), followed by the Southeast region (2,524; 27.9%).As for professional performance, the largest portion of participants provided assistance to the general public and with COVID-19 (3,810; 42.2%), were from a public institution (6,949; 76.9%) and from the infirmary sector (2,382; 26.4%).To be continued related to the material, followed by a lack of knowledge about SP and a higher workload than usual, were indicated as complicating factors, as shown in Table 2. Participants reported the intention to follow SP even when patients are difficult or there is little time.
In the analysis of SPQ-PB factor scores according to professional category (Table 4 this is an individual factor that directly interferes with the process of whether or not health workers adhere to SP (12) , as step that imply personal perception of risk and, consequently, the extent of protection adopted and risk behavior assumed.Therefore, professionals who recognize their work environment as low or

DISCUSSION
The present study assessed the socio-cognitive factors determining SP adherence by nursing professionals in care practice during the COVID-19 pandemic in Brazil.Participants recognized SP as effective measures to reduce infections and reported their intention to perform them.
The perception of effectiveness, knowledge of preventive measures as well as intention to perform them are fundamental, as of
medium risk are more likely to have an accident, when compared to those who assess the risk as high, because adherence to PPE is closely related to the perception that professionals have about the risks to which they are exposed (17) .
A study carried out in midwestern Brazil found that the nursing team's knowledge about SP was lower than recommended.Furthermore, it showed that individual factors, related to work, including the perception of risk and obstacles to following SP, in addition to organizational factors, such as training and availability of PPE, impact SP adherence (18) .Such data converge with the findings of this research, in which, in the domains of organizational and individual constraints, problems related to the material, including quality, availability and accessibility of PPE, were indicated as complicating factors, followed by the lack of knowledge about SP, mentioned previously, and a higher workload.
Unsatisfactory knowledge can impact low adherence rates and may be correlated with gaps in professional training, in addition to self-confidence resulting from years of professional experience, gap between knowledge and practice, and out-of-date current research, hampering solid knowledge bases for infection prevention and control.Furthermore, long working hours can trigger stress and fatigue, which can affect professionals' cognition processes, with consequent harm to the application of safety measures (3,19) , such as SP.
With regard to the facilitating organization domain, training in SP was highlighted as a facilitator of adherence.Thus, the need for training is highlighted, through health education activities with a focus on SP adherence and its intervening factors, as it is a complex, dynamic, multifaceted topic of organizational responsibility, which enables professionals to raise awareness and awareness regarding the relevance of adhering to SP (18)(19) .It is noteworthy that professionals show greater adherence immediately after training carried out by health institutions, however, measures are discontinued over time.Therefore, the relevance of continued and permanent educational strategies is observed, in addition to constant training for action effectiveness (3,19) .
Among the main reasons for low SP adherence and contact, the review highlighted individual factors, deficiencies in training, organizational structure, problems related to unit management and working conditions (3) .Therefore, institutional management is essential for the team's participation in these activities and training to occur continuously, through a care environment favorable to adherence, with PPE in sufficient quality and quantity, easily accessible, to facilitate and encourage its use, in addition to an institutional safety climate (18) , provided by a physical structure and quality supervision, combined with standardization and socialization of routines (12) .An unsafe environment implies a reduction in professionals' motivation and interest, predisposing them to errors and injuries (20) .
With regard to the work environment/social influence, they recognize that they run the risk of receiving warnings from their superiors if they do not follow SP, which demonstrates management's concern regarding the topic and its implications for professionals and patients.This reflects a positive institutional perception, as long as a favorable care environment is provided for the application of these measures, such as physical structure and quality materials, as mentioned previously.
Constant coexistence with exposure to biological material, which impacts the lack of fear of contamination, and the belief that nothing will happen, increasing workers' feeling of self-confidence, favor the reduction of risk perception by professionals, one of the most complex (individual) factors, influencing professionals' behavior and hindering decision-making for SP adoption (12) .Therefore, having a co-worker adopting preventive measures correctly favors risk environment perception and greater SP adherence, whereas, in environments where interpersonal relationships are not healthy, it impacts the lack of motivation for use.Therefore, co-workers can influence positively or negatively (20) .
Therefore, adherence to PPE is determined by the context experienced, in the work environment, and by individual values and beliefs, but the decision about use in general is individual.Individual factors, such as discomfort, inconvenience, carelessness, forgetfulness, lack of habit and disbelief, can be greatly aggravated by institutional/organizational, such as precarious infrastructure, lack of sufficient and quality PPE, lack of knowledge due to the lack of permanent education and work overload, which imply physical and mental exhaustion, impacting cognition (20) .Therefore, recognizing individual and institutional factors is of utmost importance, aiming to provide bases that minimize barriers, weaken the perception of susceptibility and severity to risk and reduce SP adherence, favoring facilitators.
A study that applied the SPQ-PB with 300 healthcare professionals showed that nurses had a significant effect on intention (4.77; p=0.000) and individual constraints (3.52; p=0.041) (16) scores, similar to present research.

Study limitations
The research presents as a limitation the possibility of an overrepresentation of professionals with skills in relation to the use of computers and social networks, given their online development.However, given the high number of participants, such limitations did not significantly interfere with the results.

Contributions to nursing, health, or public policy
The results can contribute to a greater understanding of the determining factors in SP adherence and, thus, enable new intervention strategies to reduce hindering factors and promote facilitators in these professionals' work practice, including the prioritization of this topic in training programs, elaboration and/or reformulation of public policies and institutional protocols, thus aiming to reduce cross-infections and occupational risks caused by low adherence or erroneous use of SP, with consequent institutional losses.

CONCLUSIONS
Among the determining factors in SP adherence by nursing professionals in care practice during the COVID-19 pandemic in Brazil, the facilitating organization factor presented the highest score, therefore, the greatest impact on adherence, followed by intention to perform standard precautions.Furthermore, participants recognized SP as effective measures to reduce infections and highlighted training as a facilitator of SP adherence and problems related to the material as the main obstacle.
In view of these findings, it was possible to develop intervention strategies, training, training and continuing education that focus on the main factors determining SP adherence, in addition to targeting strategies to improve adherence to them, to thus strengthen patient safety, reduce exposure and occupational risks among healthcare professionals as well as the occurrence of occupational accidents.

CONTRIBUTIONS
Santos AST, Silva ACO, Pereira-Ávila FMV, Coêlho HFC, Sousa LRM, Reis RK and Gir E contributed to the conception or design of the study/research.Santos AST, Silva ACO, Pereira-Ávila FMV, Coêlho HFC, Sousa LRM, Reis RK and Gir E contributed to the analysis and/or interpretation of data.Santos AST, Silva ACO, Pereira-Ávila FMV, Coêlho HFC, Sousa LRM, Reis RK and Gir E contributed to the final review with critical and intellectual participation in the manuscript.

Brazilian
National Council for Scientific and Technological Development (CNPq -Conselho Nacional de Desenvolvimento Científico e Tecnológico).

and of Sociocognitive factors determining compliance with standard precautions by nursing professionals during the COVID-19 pandemic Santos
AST, Silva ACO, Pereira-Ávila FMV, Coêlho HFC, Sousa LRM, Reis RK, et al.

Table 2 -
Distribution, percentage, mean and standard deviation according to items from the Brazilian version of the Standard Precautions Questionnaire, answered by nursing professionals (N=9,039), Brazil, 2020

Table 3 -
Score of socio-cognitive determinants referring to the factors of the Brazilian version of the Standard Precautions Questionnaire of nursing professionals (N=9,039), Brazil, 2020

Table 4 -
Score of socio-cognitive determinants referring to the factors of the Brazilian version of the Standard Precautions Questionnaire by professional category of nursing (N=9,039), Brazil, 2020 *Mann-Whitney test.